ATrain Education

 

Continuing Education for Health Professionals

Overmedication: A Hazard for Elders

Module 3

Adverse Effects of Overmedication

 

Leona’s symptoms of slurrred speech, disorientation, and confusion are classic for overmedication. Leona also experienced drowsiness and slight confusion, which she mistakenly identified as normal for her since she is aging. When she woke up from her second daytime nap, she stumbled to get up to the bathroom and thought it was just because she was still drowsy.

She had to brace herself against the wall down the hall to the bathroom and passed it off to her being clumsy. After speaking to her son on the phone she couldn’t remember what the conversation was about. Her husband, who takes eight medications for his own declining health, wasn’t able to identify her changing behavior nor associate it with overmedication use.

 

Healthcare providers need to be alert to the potential for polypharmacy and its complications. It is essential to identify risk factors in the patients we treat in order to manage medications appropriately (see table below).

Risks Overview

Polypharmacy increases the risk of potentially inappropriate prescriptions, cognitive disorders, falls, hip fractures, depression, and incontinence. Inappropriate medications complicate polypharmacy because many of the drugs classified as potentially inappropriate are associated with ADRs, some offer little or no advantage over other safer drugs, and some have a long half-life in older patients (Lococo & Staplin, 2006).

 

Source: Lococo & Staplin, 2006.

Risk Factors for Adverse Effects from Polypharmacy

Category

Characteristic(s) indicating high risk

Age

Over 75 years of age

Living situation

Living alone or with an elderly spouse

Medications

Taking multiple drugs, OTC, social drugs

Medical

  • Multiple prescribers, such as physicians, psychiatrists, dentists, podiatrists, or nurse practitioners
  • Multiple medical problems
  • Multiple caregivers
  • Poor communication between older patients and health professionals

Cognition

  • Impaired alertness or memory
  • Psychiatric problems
  • Inability to take medications as directed

Physical

  • Appears weak and with impaired mobility
  • Needing a walker or cane

 

Risk for Falls

It has been well-established that polypharmacy is a risk factor for falls. An estimated 30% of elders report falling each year, and falls claim the leading cause of fatal and nonfatal injuries among adults age 65 and older (CDC, 2016b). In 2014, based on the Behavioral Risk Factor Surveillance System (BRFSS) survey, an estimated 27,000 older adults died because of falls, 800,000 were hospitalized, and 2.8 million were treated in emergency departments (Eds) for falls. In a single year, 30% of people over 65 years of age and 50% of those age 80 or older will fall (Masud & Morris, 2001).

Classes of medications that have been linked to increased fall risk, especially in elders, include nonsteroidal anti-inflammatory drugs (NSAIDS), benzodiazepines, anticholinergics, opioids, antidepressants, and neuroleptics (Ponce, 2012; CDC, 2007). It is recommended that each of these medications begin at low-dose entry levels and titrate upward slowly as needed. Careful monitoring should be done within the first 2 weeks of drug therapy with benzodiazepines, opioids and antidepressants when the fall and fracture risk is highest.

Assessment tools have been created, and there are even screening tools for fall-risk prediction in elders (Bongue et al., 2010). The Home Health Quality Improvement organization has gathered helpful research and created practice guidelines for medication management. Physicians, nurse practitioners, and physical therapists have also identified key factors that need to be assessed for fall and fracture risk. They include the following:

  • Postural hypotension
  • Use of sedatives
  • Use of at least four prescription medications
  • Impairment in arm or leg strength or range of motion
  • Balance
  • Ability to move safely from bed to chair or to the bathtub or toilet (transfer skills)
  • Gait

Less well known is that fall risk can increase significantly in the days following a medication change. In October 2004, researchers at Johns Hopkins University studied the effect of medication changes on the risk of falls among residents of three nursing homes who fell during 2002–2003. The study looked at medication changes that occurred 1 to 9 days before the fall, including the odds ratio of falling after a start, stop, or dose change in medication in the case time period versus the control time period (CDC, 2007; Van Der Velde et al., 2006; Zhan, 2001).

The results indicated that the short-term risk of single and recurring falls may triple within 2 days after a medication change. The Johns Hopkins study outcomes may be used to develop similar fall risk studies in other clinical settings; to identify high-risk times for falls depending on medication changes; and to develop intensive, short-term interventions for vulnerable residents after medication changes (CDC, 2007).

A prospective study completed on patients who had a fall risk followed by a drug discontinued revealed a statistically significant improvement in fall reduction—especially after withdrawal of cardiovascular drugs that put the patient at risk for orthostatic hypotension (Van der Velde, 2006).

Another strategy to decrease fall risk is to complete a medication reconcilliation at every medical office visit or hospitalization. It is the process of creating an updated list of all the current medications a patient may be receiving and includes the dosage, route, time, purpose, and frequency of the drug. Both generic and brand names should be identified so as not to duplicate drugs. Many times a patient may be confused and be taking the drug twice as often as prescribed because the names are different even when the drug is the same.

Physicians, physician assistants, nurse practitioners, nurses and other healthcare professionals should complete medication reconciliation upon hospital admission and discharge, home visits, care plan reviews, annual comprehensive exams, office visits, and any time the patient is being transferred from one facility to another or has medication changes.

In 2015 the National Council on Aging, Center for Healthy Aging, issued the updated Falls-Free National Action Plan, in which they urged healthcare professionals to support policies that increase awareness of polypharmacy and fall risk. The goal of the call to action is to

increase the number of older adults who have annual medication reviews conducted by healthcare providers or pharmacists and ensure this review includes an adequate focus on falls and fall-related injury prevention, with the goal of reducing or eliminating medications that increase fall risk. (NCOA, 2015)

To address this goal, clinicians should regularly review each patient’s medications for potential interactions and side effects that may increase fall risk and, where possible, reduce or eliminate medications or select alternatives. Reducing the number and types of medications—particularly tranquilizers, sleeping pills, and anti-anxiety drugs—can be an effective fall prevention strategy when used alone or as part of a multi-component intervention (NCOA, 2015).

 

Answer: C

Test Your Knowledge

The risk for falls:

  1. Lessens in those relaxed through use of anti-anxiety drugs.
  2. Is generally related to impulsive behavior.
  3. May triple within two days of a medication change.
  4. Is decreased when older adults remain in the home.

 

Apply Your Learning

Q: What can you do for your patients to help assess for and prevent falls?
A: According to HHQI, you can use many fall assessment tools including the Get Up and Go test and fall risk tools such as the Fall MedQIC Fall Risk form, which answers questions about past falls, number of medications prescribed, physical strength, confusion, orientation status, and more, to come up with a number that quantifies the patient’s fall risk. Download the form at: http://www.homehealthquality.org/Education/Best-Practices/BPIPs/Fall-Prevention-BPIP.aspx. Teaching the patient about the purpose of their medications can also help them evaluate the medication’s usefulness.

 

Online Resources

Home Health Quality Improvement Fall Prevention Assessment Tools and Prevention Strategies
http://www.homehealthquality.org/Education/Best-Practices/BPIPs/Fall-Prevention-BPIP.aspx

 

National Council on Aging, 2015 Falls—Free National Falls Prevention Action Plan slides
https://www.ncoa.org/resources/2015-falls-free-national-falls-prevention-action-plan/

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